Healthcare Provider Details

I. General information

NPI: 1700570389
Provider Name (Legal Business Name): MS. MADISON GRACE MALLORY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2023
Last Update Date: 09/18/2025
Certification Date: 09/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10999 REED HARTMAN HWY SUITE 207
BLUE ASH OH
45242
US

IV. Provider business mailing address

10999 REED HARTMAN HWY SUITE 207
BLUE ASH OH
45242
US

V. Phone/Fax

Practice location:
  • Phone: 513-999-5506
  • Fax:
Mailing address:
  • Phone: 513-999-5506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.2507511
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: